Outcome of the management of massive postpartum hemorrhage using the algorithm “HEMOSTASIS”

Outcome of the management of massive postpartum hemorrhage using the algorithm “HEMOSTASIS”

International Journal of Gynecology and Obstetrics 113 (2011) 152–154 Contents lists available at ScienceDirect International Journal of Gynecology ...

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International Journal of Gynecology and Obstetrics 113 (2011) 152–154

Contents lists available at ScienceDirect

International Journal of Gynecology and Obstetrics j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j g o

CLINICAL ARTICLE

Outcome of the management of massive postpartum hemorrhage using the algorithm “HEMOSTASIS” Lavanya Varatharajan a,⁎, Edwin Chandraharan b, Julian Sutton b, Virginia Lowe b, Sabaratnam Arulkumaran b a b

St George's University, London, UK Department of Obstetrics and Gynecology, St George's Healthcare NHS Trust, London, UK

a r t i c l e

i n f o

Article history: Received 3 June 2010 Received in revised form 5 November 2010 Accepted 27 January 2011 Keywords: Cesarean delivery Hemostasis Hysterectomy Postpartum hemorrhage

a b s t r a c t Objective: To evaluate whether the algorithm “HEMOSTASIS” (help; establish etiology; massage the uterus; oxytocin infusion and prostaglandins; shift to operating theater; tamponade test; apply compression sutures; systematic pelvic devascularization; interventional radiology; subtotal/total abdominal hysterectomy) was of value in the systematic management of postpartum hemorrhage (PPH). Methods: A retrospective analysis was performed of all women who experienced massive primary PPH (blood loss N 1500 mL) in 2008 at St George's Hospital, London, UK. The success of the HEMOSTASIS mnemonic in PPH management was determined by assessing clinical outcome following adherence to the protocol. Results: Patient notes were available for 95 (83.3%) of the 114 cases of primary PPH. Hemostasis was achieved in 63 (66.3%) women via use of additional oxytocics (“O”); 19 (20.0%) via suture of tears and 10 (10.5%) via tamponade (“T”); 1 (1.1%) via application of compression suture (“A”); 1 (1.1%) via systematic devascularization (“S”); and 1 (1.1%) via subtotal/total hysterectomy (“S”). There were no maternal deaths. Conclusion: The decremental pattern of more complex interventions used demonstrates that the algorithm can provide a logical management pathway to reduce blood transfusions, hysterectomies, admissions to intensive care units, and maternal deaths. Crown Copyright © 2011 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics. All rights reserved.

1. Introduction The success of modern obstetrics continues to be challenged by cases of postpartum hemorrhage (PPH). This life-threatening complication of childbirth is the most common type of obstetric hemorrhage, accounting for 10.6% of all direct maternal deaths in the UK [1]. The situation in low-income countries is much worse, with one-quarter of all maternal deaths attributed to obstetric hemorrhage [1]. The main reason for deaths following PPH has been described previously as “too little, too late” [1], meaning that interventions do not take place in a timely manner and that not enough oxytocics and fluids, including blood, are given. The mnemonic “HAEMOSTASIS” (amended to “HEMOSTASIS” in the present study: a term that should be used in future to enable uptake in non-UK hospitals) was proposed to provide, in a stepwise manner, a logical and timely approach for the management of PPH and to avoid delay in clinical management [2]. Before the introduction of the algorithm in 2005, the management of PPH was carried out as indicated by the mnemonic but in different sequences. Additional training in obstetric emergency skills and drills—similar to that described in A Textbook of Postpartum Hemorrhage [3]—was given to

staff at St George's Hospital, London, UK, so that each step in the algorithm would be followed in rapid succession until bleeding was arrested. The details of each stage of the updated mnemonic are as follows [4]: help (request help from additional and senior staff [obstetricians, midwives, anesthetists, and hematologists], and assess airway, breathing, circulation, and vital parameters); establish etiology (tone, tissue, trauma, and thrombin), and ensure availability of blood and ecbolics (bolus oxytocin, oxytocin and ergometrine, and ergometrine); massage the uterus; oxytocin infusion and prostaglandins (intravenous [IV], per rectum, intramuscular, or intramyometrial); shift to operating theater, with bimanual uterine/aortic compression or anti-shock garment during transfer; tamponade test (tissue, trauma, and thrombin problems to be excluded before proceeding to tamponade test); apply compression sutures (B-Lynch or modified compression sutures); systematic pelvic devascularization (uterine, ovarian, quadruple, internal iliac); interventional radiology (if appropriate, uterine artery embolization); subtotal/total abdominal hysterectomy. The aim of the present study was to investigate whether the algorithm HEMOSTASIS was followed in a busy labor ward setting and whether it was effective in the management of PPH. 2. Materials and methods

⁎ Corresponding author at: St George's University, Cranmer Terrace, London SW17 0RE, UK. Tel.: +44 7894829462; fax: +44 2087255958. E-mail address: [email protected] (L. Varatharajan).

A retrospective analysis was undertaken of all women who experienced massive primary PPH (total blood loss N1500 mL) between

0020-7292/$ – see front matter. Crown Copyright © 2011 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics. All rights reserved. doi:10.1016/j.ijgo.2010.11.021

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January 1 and December 31, 2008, at St George's Hospital. The following data were obtained from each of the women's case notes: age; parity; gravidity; gestational age (weeks); total blood loss; risk factors predisposing to PPH; type of labor; duration of first, second, and third stages of labor; evidence of clinical infection and antibiotics given for treatment; mode of delivery; third-stage complications; cause of PPH; complete or incomplete placenta and membranes; IV fluids; blood or blood product replacement; medical and surgical treatment; admission to intensive care unit (ICU); whether “code blue” (bleep for consultant obstetricians and anesthetists) was called; and which stages of the HEMOSTASIS mnemonic were performed. To audit consultant presence (“H”), cases were divided into 2 groups: those in which blood loss (quantified via visual estimation) was 1500–2000 mL; and those in which blood loss was more than 2000 mL. The analysis was performed in this way because, although the consultant obstetrician can be called at any time at the study hospital, the protocol stipulates that it is mandatory for a code blue to be activated and for the whole team to attend to women with more than 2000 mL of blood loss. The times of onset of hemorrhage, initiation of the call, and attendance of the consultant were not clearly recorded for detailed analysis. For all other outcome measures, the cohort was not divided into groups. Prolonged labor was defined as a first stage of more than 12 hours, a second stage of more than 3 hours, and a third stage of more than 30 minutes. All data were analyzed via Microsoft Excel (Microsoft, Redmond, WA, USA). 3. Results During the study period, there were 5015 deliveries at St George's Hospital. In total, 114 (2.3%) women experienced massive primary PPH. Notes were available for 95 (83.3%) women, who were the subject of the present study. Of these women, 64 (67.3%) lost 1500– 2000 mL of blood and 31 (32.6%) lost more than 2000 mL. The patient notes revealed that help was requested (via code blue) in 84% of cases in which more than 2000 mL of blood was lost. The median age of the women was 33 years (range, 15–48 years). Fifty-two (54.7%) women were nulliparous, compared with 43 (45.3%) who were multiparous. Median gestational age at delivery was 40 weeks (range, 26–42 weeks) and median blood loss among the women was 1775 mL (range, 1500–15 000 mL). Eighty-eight (92.6%) women had at least 1 risk factor for PPH, whereas 7 (7.4%) women had none. The most prevalent risk factors were: cesarean delivery in the index pregnancy (64.2%); prolonged labor (35.8%); manual removal of the placenta (25.3%); previous cesarean (16.8%); multiple pregnancies (8.4%); instrumental vaginal delivery (8.4%); placenta previa (6.3%); fibroid uterus (5.3%); prepartum hemorrhage (4.2%); history of PPH (3.2%); infection/pyrexia (2.1%); placenta accreta (2.1%); and polyhydramnios (1.1%). Of the 61 (64.2%) cases of cesarean delivery, 50 (82.0%) were emergency and 11 (18.0%) were elective. Active management of the third stage of labor (accompanied by uterine massage) was practiced in all cases. Oxytocin and ergometrine—and, in some cases (those with hypertension), oxytocin only—were the uterotonic agents used. Manual removal of the placenta was the most common third-stage complication, occurring in 24 (25.3%) cases. Twelve (12.6%) women had retained tissue, but none had uterine inversion. Uterine atony was the most frequent cause of PPH, affecting 61 (64.2%) women, followed by vaginal tears (Fig. 1). All 95 women received IV fluids, 25 (26.3%) received colloids, and 38 (40.0%) underwent blood transfusion—of whom 17 (44.7%) received fresh frozen plasma and 8 (21.2%) received platelets. Those who received fresh frozen plasma and platelets had experienced total blood loss greater than 2000 mL. All women received 40 units of oxytocin in 500 mL of normal saline (Table 1). Twenty-six (27.4%) women were treated with oxytocin infusion alone, and needed no other medical or surgical

153

Fig. 1. Causes of postpartum hemorrhage (PPH). There was more than 1 cause of bleeding in some women. *Coagulation abnormalities followed excess bleeding due to atonic uterus.

treatment to achieve hemostasis. Thirty-seven (38.9%) women received 800 μg of rectal misoprostol. Thirty-two (33.7%) women required surgical treatment, 24 (75.0%) of whom underwent suturing of vaginal tears (19 [79.2%] underwent suturing of vaginal tears only, and 5 [20.8%] underwent suturing of vaginal tears but also needed balloon tamponade to stop the bleeding). Of the 13 (13.7%) cases overall of balloon tamponade, the procedure was successful in 10 (76.9%). In the remaining 3 cases—in which laparotomy was also required because of difficulty in arresting bleeding—1 woman required uterine compression sutures, 1 required ligation of the uterine and uterine branches of the ovarian vessels, and 1 underwent hysterectomy. None of the women underwent ligation of internal iliac vessels, embolization of internal iliac or uterine arteries, or subtotal hysterectomy. Five (5.3%) women were admitted to the ICU. There were no maternal deaths.

4. Discussion With only 1 total hysterectomy and no maternal deaths among the 95 analyzed cases of massive PPH at the study hospital in 2008, it seems that the HEMOSTASIS algorithm is of value in the management of PPH. The identified risk factors for PPH are not new and reiterate what has previously been found [3], with the 5 main predispositions in the present study being cesarean delivery, prolonged labor, manual removal of the placenta, previous cesarean, and multiple pregnancies. Furthermore, the majority of PPH cases were due to uterine atony, consistent with the current literature [5]. The protocol was followed in the majority of cases—help was requested in 84% of cases in which more than 2000 mL of blood was lost, although the protocol did state that help should be requested in all such cases. Furthermore, all women underwent active management of the third stage of labor and received oxytocin or prostaglandins— indicating that the categories “H,” “E,” “M,” and “O” of the algorithm were followed. Only 32 (33.7%) women required additional surgery, which indicates that the majority responded to medical management and uterine massage.

Table 1 Medical treatment received by study participants. Treatment

Participants (n = 95)

Additional syntometrine Additional ergometrine Oxytocin (40 units in 500 mL of normal saline) Parenteral prostaglandins Rectal misoprostol

27 10 95 29 37

(28.4) (10.5) (100.0) (30.5) (38.9)

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The 2006 Scottish Confidential Audit of Severe Maternal Morbidity [6] reported the incidence of major obstetric hemorrhage to be 5 per 1000 births, compared with 3.5 per 1000 in 2003. However, the near misses: death ratio decreased from 1:56 in 2003 to 1:87 in 2006. The use of balloon tamponade increased from 6 in 2003 to 42 in 2006 (the success rate was 95%), the use of hemostatic compression sutures increased from 10 in 2003 to 24 in 2006 (the success rate was 83%), and the postpartum hysterectomy rate decreased from 15% in 2003 to 8% in 2006 [6]. Similarly high success rates of 80%–90% for simple balloon tamponade and compression suture procedures have been reported in a systematic review [7]. The approach taken in Scotland was consistent with that represented by the HEMOSTASIS algorithm. Furthermore, the recent guidelines from the Royal College of Obstetricians and Gynaecologists (RCOG) on the prevention and management of PPH also recommend a similar algorithm [8]. Only 5.3% of studied cases of massive primary PPH were admitted to the ICU. This indicates that, despite women sustaining massive PPH, cases were managed well via timely arrest of bleeding and good hemodynamic management—leading to prevention of coagulopathy and metabolic acidosis in the vast majority of cases. Adhering to the HEMOSTASIS protocol meant that total hysterectomy for massive PPH was performed in just 1 (1.1%) case during the study period. The patient who underwent hysterectomy had placenta percreta invading the bladder, was multiparous (gravida 6, para 5), and had 5 previous cesarean deliveries—which put her at increased risk of obstetric hemorrhage. Initially, she received oxytocics, uterine compression sutures, and systematic pelvic arterial devascularization during cesarean. She subsequently underwent uterine artery embolization and was admitted to the ICU. Hysterectomy was performed as a life-saving measure after a further 4000 mL of blood loss (with total loss of 15 000 mL). The short time in which a woman's condition can rapidly deteriorate means that healthcare professionals must think clearly and act effectively. It is at such times that practice drills using the mnemonic HEMOSTASIS can provide a quick and methodic approach for the management of massive PPH. Skupski et al. [9] reported improved outcomes and a reduction in maternal mortality, despite an increase in cases of major obstetric hemorrhage, after implementing a multidisciplinary obstetric rapid-response team—similar to cardiac arrest teams—with protocols designed to expedite the management of PPH. Such multidisciplinary teams and the progression from simple to complex techniques can help to stop more than 90% of hemorrhages,

as shown in the present study and the Scottish near-miss audit [6]. A stepwise approach should help to reduce major surgeries such as hysterectomy and ligation of internal iliac vessels, and save many lives in resource-poor countries. The addition of misoprostol and balloon tamponade should be considered for basic obstetric emergency functions, which currently include the use of IV oxytocin and manual removal of the placenta, because the skills needed are similar. The same argument exists for adding compression sutures to comprehensive emergency obstetric functions, which involve cesarean delivery and blood transfusion. Many deaths due to PPH could be prevented by the inclusion of simple measures followed in a sequential manner using the HEMOSTASIS algorithm. Conflicts of interest The authors have no conflicts of interest. References [1] The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives: Reviewing Maternal Deaths to Make Motherhood Safer 2003–2005. www.cmace.org.uk. http://www.cmace.org.uk/getattachment/26dae364-1fc94a29-a6cb-afb3f251f8f7/Saving-Mothers%E2%80%99-Lives-2003-2005-(Full-report). aspx. Published 2007. [2] Chandraharan E, Arulkumaran S. Management algorithm for atonic postpartum haemorrhage. J Paediatr Obstet Gynaecol 2005;31(3):106–12. [3] Tipples M, Paterson-Brown S. Labor Ward Drills. In: B-Lynch C, Keith LG, Lalonde AB, Karoshi M, editors. A Textbook of Postpartum Hemorrhage. UK: Sapiens Publishing; 2006. [4] Doumouchtsis SK, Arulkumaran S. Postpartum Haemorrhage—Changing Practices. In: Dunlop W, Ledger WL, editors. Recent Advances in Obstetrics and Gynaecology, 24. London: Royal Society of Medicine Press; 2007. p. 89–104. [5] Drife J. Management of primary postpartum haemorrhage. Br J Obstet Gynaecol 1997;104(3):275–7. [6] Penney G, Adamson L. Scottish Confidential Audit Severe Maternal Morbidity. 4th Annual Report 2006. www.nhshealthquality.org. http://www.nhshealthquality. org/nhsqis/files/Maternityservices_SPCERH30_4thAnnualReport_2006.pdf. Published 2007. Updated 2009. Accessed 2010. [7] Doumouchtsis S, Papageorghiou AT, Arulkumaran S. Systematic review of conservative management of postpartum hemorrhage: what to do when medical treatment fails. Obstet Gynecol Surv 2007;62(8):540–7. [8] Arulkumaran S, Mavrides E, Penney GC. Prevention and Management of Postpartum Haemorrhage – Green top Guideline No 52. www.rcog.org.uk. http://www.rcog.org. uk/files/rcog-corp/Green-top52PostpartumHaemorrhage.pdf. Published 2009. Accessed 2010. [9] Skupski DW, Lowenwirt IP, Weinbaum FI, Brodsky D, Danek M, Eglinton GS. Improving hospital systems for the care of women with major obstetric hemorrhage. Obstet Gynecol 2006;107(5):977–83.